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Name: Fillable Online Syphilis Case Report Form. A case report form on syphilis disease for public health units. Fax Email Print - pdfFiller
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Case name: ......................................................................................... First name DOB ......../......../........ Person ID: .............................. SurnameSyphilis

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How to fill out syphilis case report form

01

Step 1: Download the syphilis case report form from the official website of the relevant health authority.

02

Step 2: Fill in the general information section, including the patient's name, age, gender, and contact details.

03

Step 3: Provide details about the healthcare facility where the diagnosis was made, including the name, address, and contact information.

04

Step 4: Specify the date of diagnosis and the stage of syphilis identified.

05

Step 5: Record the results of the laboratory tests conducted for syphilis, including the type of test and the results obtained.

06

Step 6: Document the treatment provided to the patient, including the type of medication administered and the duration of treatment.

07

Step 7: Include any additional remarks or findings related to the case.

08

Step 8: Verify the accuracy of the filled-out form and sign it as the reporting healthcare professional.

09

Step 9: Submit the completed syphilis case report form to the designated health authority according to their specified submission methods and deadlines.

Who needs syphilis case report form?

01

Healthcare professionals who diagnose and treat syphilis cases are required to fill out the syphilis case report form.

02

Clinics, hospitals, and other healthcare facilities with diagnosed syphilis cases are also responsible for submitting these forms.

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